U.S. Health Care Systems

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Access

The ability of persons needing health services to obtain appropriate care in a timely manner.

Access (Explanation)

Can ou get medical care when yyou need it? if yes, you have access to meical care. Access is not the same as health isurance coverage, although insurance coverage is a stron predicator of access for primary care services.

Administrative Costs

Cost that are incidental to the delivery of health services.

Administrative Cost (explanation)

These costs are not only associated with the billing and collection of claims for services deliverded but also include numerous other costs, such as time and effort incurred by employers for the selection of insurance carriers, cost incurred by isurance and managed care organizations to market their products and time and effort involved in the negotiation of rates

Balance Bill

Billin the leftover sum by the provider to the patien after insuarce has only partiallly paid the charge initially billed

Capitation

A reimbursement mechanism under which the provider is paid a set monthly fee per enrolle (sometimes refered to as "per member per month [PMPM] rate, regardless of whether or not an enrollee sees the provider and regardless of how often an enrollee sees the provider.

Defensive Medicine

Excessive medical test and procedures performed as a protection against malpractice lawsuits, otherwise regarded as unnessesary

A systerm that combines the functions of health insurance and the actual delivery of care, where costs and utilisation of services are controlled by such mathods as gatekeeping, case management, and utilization review.

Medicaid

A joint federal-state program of health insurance for the poor

Medicare

A federal program of health insurance for the elderly and some disabled persons

Moral Hazard

Consumer behavior that leads to higher utilization of healthcare servcises because people are covered by insurance

National Health Insurance

the goverment finances healthcare through general taxes, but the actual care is delivered by private providers

National Health System

in addition to financing a tax-supportted NHI program, the government also manages the infastructure for the delivery of medical care (sidenote: the goverment owns must of the medical institutions

Need

generally defined as the amount of medical care that medical experts believe a person should have to remain or become healthy. Can also be based on self-evaluation of one's own health status

Outpatient Care

Most health care services are delivered in noninstituional settings mainly associated with processes reffed to as outpatient care

Package Pricing

Bundling of fees for and entire package of related services

Phantom Providers

examples: anesthetist, nurse anesthetist and pathologist

They function in an adjunct capacity and bill for their services seprately.

Premium Cost Sharing

Employers rarely pay 100 percent of insurance permium; most require their employees to pay a portrion of the cost

Primary Care

Basic and routine health care that is provided in an office or clinic by a provider (physician, nurse, or other health care professional) who takes responsibility for coordinating all of a patien's health care needs. An approach to health care delivery that is the patien'ts first contact with health care delivery system and the first element of a continuing health care process.

formulated by the government through health policy and regulation; providers must comply with the stardards established by the government to be certified to provide services to Medicaid, SCHIP, and Medicare beneficiaries

Certification standars are regarded as minimum standards of quality in most sectors of the health care industry

Supplier-induced demand

when providers increase demand by prescribing medical care beyond what is clinically necessary. such as follow up appts, excessive medical test, and unnessary surgery

System

network of interrelated components designed to work together coherently

Third-Party

payment and insurance fuctions intoruce a third party into the transaction. ( patient is 1st, provider is 2nd)

Uninsured

without private or public health insurance coverage

Utilization

Extent to which health care services are actually used. For example, the number of physicians visits per person per year is a measure of utilization for primary care services